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Percutaneous left atrial decompression in patients supported with extracorporeal membrane oxygenation for cardiac
Lucas J Eastaugh1, Ravi R Thiagarajan, Jeffrey R Darst
11Department of Cardiology, Boston Children's Hospital, Boston, MA. 2Department of Pediatrics, Harvard Medical School, Boston, MA.
Insights
Percutaneous left atrial decompression effectively reduces pulmonary edema in pediatric extracorporeal membrane oxygenation (ECMO) patients. Various catheter techniques are successful, with persistent atrial septal defects noted in some survivors.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Critical Care Medicine
Background:
- Left atrial decompression is crucial for managing cardiogenic edema and ventricular distension in patients on extracorporeal membrane oxygenation (ECMO).
- Percutaneous techniques offer a less invasive approach to left atrial decompression compared to surgical methods.
Purpose of the Study:
- To describe the experience with percutaneous left atrial decompression techniques at Boston Children's Hospital.
- To evaluate the acute outcomes and clinical impact of these procedures in pediatric ECMO patients.
Main Methods:
- Retrospective analysis of pediatric patients undergoing percutaneous left atrial decompression while on ECMO.
- Patients were categorized into myocarditis/suspected myocarditis and nonmyocarditis cardiac disease groups.
- Interventions included vent placement, static balloon dilation, and stent implantation.
Main Results:
- Percutaneous left atrial decompression was performed in 10.5% of ECMO cases, frequently for myocarditis (50%).
- All techniques significantly reduced left atrial pressure and pulmonary edema, with radiographic improvement within 48 hours.
- Survival to discharge was not associated with ECMO duration, pressure change, or technique; 5/44 survivors had residual atrial septal defects, with 2 requiring closure.
Conclusions:
- Percutaneous left atrial decompression is an effective strategy in pediatric ECMO patients.
- Various percutaneous techniques yield successful outcomes in reducing pulmonary venous congestion.
- Persistent atrial septal defects may necessitate closure during follow-up.
Objectives:
Left atrial decompression using cardiac catheterization techniques has been described at centers with extracorporeal membrane oxygenation programs. Left atrial decompression can decrease cardiogenic edema, minimize ventricular distension, and allow myocardial recovery. We describe Boston Children's Hospital's experience with percutaneous left atrial decompression techniques, acute outcomes, and clinical impact of left atrial decompression in extracorporeal membrane oxygenation patients.
Subjects:
Patients supported with extracorporeal membrane oxygenation undergoing percutaneous left atrial decompression were identified and assigned to two groups 1) myocarditis/suspected myocarditis or 2) nonmyocarditis cardiac disease.
Interventions:
Three techniques including vent placement, static balloon dilation, and stent implantation were used.
Measurements And Main Results:
Change in left atrial pressure and severity of pulmonary edema on chest radiography pre and post procedure, impact of timing and technique of left atrial decompression on resolution of left atrial hypertension, and extracorporeal membrane oxygenation survival were evaluated. Furthermore, we evaluated the presence of residual atrial septal defect during follow-up. Percutaneous left atrial decompression was performed in 44 of 419 extracorporeal membrane oxygenation cases (10.5%) and was frequently used for myocarditis (22 of 44 patients; 50%). Techniques included 25 vents, 17 static balloon dilations, and two stents. All techniques were equally successful and significantly reduced left atrial pressure and pulmonary edema. Survival to hospital discharge was not associated with extracorporeal membrane oxygenation duration prior to left atrial decompression, change in left atrial pressure, or technique used. Persistent atrial septal defect was noted in five surviving patients (excluding transplant recipients and deceased), two required closure.
Conclusions:
Left atrial decompression can be performed effectively in children on extracorporeal membrane oxygenation using various percutaneous techniques. Reduction in pulmonary venous congestion is usually evident by chest radiography within 48 hours of intervention. Persistent atrial septal defect may require closure at the time of extracorporeal membrane oxygenation decannulation or during long-term follow-up.
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